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Fluorodopa F-18 [18F]FDOPA Fluorodopa F-18 [18F]FDOPA Radiopharmaceutical Name L-3,4-Dihydroxy-6-[18F]fluorophenylalanine. Also known as: Fluorodopa F18, 18F- fluorodopa, [18F]Fluorodopa, 18F-6-L-fluorodopa, [18F]-fluoro-L-DOPA, L-6-[18F]fluoro-3, 4- dihydroxyphenylalanine, 6-[18F]Fluoro-L-DOPA. 18 Abbreviations: FDOPA, -FDOPA. Radiopharmaceutical Image Normal Biodistribution Radiopharmaceutical Structure 18 The F-FDOPA biodistribution resembles the normal distribution of L-DOPA. It crosses the blood-brain barrier, where it is converted to 18F-Fluorodopamine by dopa decarboxylase. 18F-Fluorodopamine is stored intraneuronally in vesicles. Maximum intensity projection (left) and 2 coronal images of normal 18F-FDOPA biodistribution (uptake in basal ganglia, myocardium, mild uptake in skeletal muscle; excreted activity in urinary tract; uptake in pancreas was suppressed by premedication with carbidopa ) courtesy of Karel Pacak, MD, PhD (NICHD, NIH) Radionuclide 18F Half-life 109.7 minutes Emission Emission positron: Emax 1.656 MeV Developed by the SNMMI PET Center of Excellence and the Center for Molecular Imaging Innovation & Translation May 2013 - 1 Fluorodopa F-18 [18F]FDOPA MICAD http://www.ncbi.nlm.nih.gov/books/NBK23043/ Molecular Formula and Weight C9H10FNO4 2145.18 g/mole General Tracer Class Investigational Diagnostic PET Radiopharmaceutical in the US; approved for clinical use in some European countries under the name IASODopa® Target 1. Neurology/Psychiatry: Dopamine receptors in the brain (1-3) 2. Oncology: a) Amino acid (AA) transporters (a feature of many benign and malignant tumors); b) overexpression of DOPA decarboxylase is a characteristic feature of neuroendocrine tumors (NET); this enzyme is usually co-expressed with other neuroendocrine markers such as chromogranin-A (4). Molecular Process Imaged 1. Regional distribution of neurotransmitter dopamine in the brain. 2. Amino acid uptake and metabolism in tumors Mechanism for in vivo retention 1. Neurology/Psychiatry: 18F-FDOPA crosses the blood-brain barrier where it is converted to 18F-Fluorodopamine by enzyme amino acid decarboxylase (AADC) in the striatum. 18F- Fluorodopamine is stored in presynaptic vesicles until the neuron activation triggers its release and subsequent binding to the dopamine receptors. (1-3, 5). 2. Oncology: [18F]-FDOPA is taken up into cancer cells by (predominantly L-type) AA transporters, which are overexpressed in cancer (6). In the cancer cell, AA may enter various pathways (e.g., peptide, protein, purine, pyrimidine or hormone synthesis; act as methyl group donors etc). FDOPA in particular undergoes decarboxylation; increased activity of L-DOPA decarboxylase is a hallmark of (benign and malignant) neuroendocrine tumors (4). In NET, F- DOPA uptake reaches a plateau within 20 min after intravenous injection, although later imaging time points may be preferred after premedication with carbidopa (see below) (7, 8). Metabolism [18F]-FDOPA is converted to 18F-Fluorodopamine by dopa decarboxylase. 18F-FDOPA is also converted to 3-O-methyl-6-fluoro-L-DOPA (3-OMFD) by catechol-O-methyl transferase (COMT) (1-3, 5). Systemic metabolism can be inhibited by prior administration of the decarboxylase inhibitor carbidopa. When used for DA receptor imaging, premedication with carbidopa increases Developed by the SNMMI PET Center of Excellence and the Center for Molecular Imaging Innovation & Translation May 2013 - 2 Fluorodopa F-18 [18F]FDOPA bioavailability and cerebral uptake of F-DOPA. When used for oncologic indications in the torso, carbidopa (e.g., 200 mg orally 1 hour before tracer injection) improves tumor uptake of F-DOPA (higher SUV), suppresses physiologic F-DOPA uptake in the pancreas, and decreases F-DOPA urinary excretion (8), thus potentially increasing the sensitivity for detecting NETs and their metastases. Recent initial data suggest that pretreatment with COMT and MAO inhibitors, which decrease intracellular FDOPA breakdown, may improve visualization of pancreatic tumors on 18F- FDOPA PET (9). Radiosynthesis 18F-FDOPA can be synthesized either via electrophilic or nucleophilic substitution reaction methods. Additional information is available at Molecular Imaging and Contrast Agent Database (MICAD), Bethesda (MD): National Center for Biotechnology Information (http://www.ncbi.nlm.nih.gov/books/NBK23043). Developed by the SNMMI PET Center of Excellence and the Center for Molecular Imaging Innovation & Translation May 2013 - 3 Fluorodopa F-18 [18F]FDOPA Availability As for any investigational PET radiopharmaceutical, an IND, NDA or ANDA filed with the Food and Drug Administration (FDA) is required for human use. Status with USP / EuPh The radiopharmaceutical is listed in the USP and the EuPh. Recommended Activity and Allowable Mass DOSAGE AND ADMINISTRATION IV administration, typically 6-12 mCi (222-444 MBq) with a specific activity of 20 to 40 MBq (740 to 1480 mCi) per micromole (2, 3, 10, 11). Dosimetry The effective dose equivalent (whole body) is estimated to be 0.026 mSv/MBq (100 mrem/mCi) for adults. The critical organs are the kidneys, the bladder, and the pancreas; they receive 0.089 mGy/MBq (389 mrad/mCi), 0.215 mGy/MBq (797 mrad/mCi and 0.030 mGy/MBq (110 mrad/mCi) respectively (12). Pharmacology and Toxicology In vivo, 18F-FDOPA exhibits pharmacodynamics and pharmacokinetics similar to Levodopa. Following intravenous administration, about 1% of the drug crosses the blood-brain barrier, but the vast majority remains in the periphery. In the periphery, 18F-FDOPA can either be converted to 3-O-methyl-6-fluoro-L-DOPA (3-OMFD) by catechol-O-methyl transferase (COMT) or be converted to [18F]-Fluorodopamine by aromatic amino acid decarboxylase (AAAD). The 18F-Fluorodopamine can be further metabolized either via addition of the sulfate group to yield 6-[18F]-fluorodopamine sulphate or via deamination by monoamine oxidase to yield 6-[18F]-fluoro-dihydroxy-phenyl acetic acid (18F-FDOPAC). 18F-FDOPAC is methylated by COMT to give 6-[18F]-fluoro-homovanillic acid (18F-FHVA). 18F-FDOPA metabolites are mainly renally excreted. In the striatum region of the brain, 18F-FDOPA is converted to 18F- Fluorodopamine by enzyme aromatic amino acid decarboxylase (AAAD), which is stored in pre-synaptic vesicles. In the non-dopaminergic regions of the brain, there is limited 18F- FDOPA metabolic activity. The toxicology of 18F-FDOPA is not fully investigated. Current Clinical Trials The NIH clinical trials registry (www.clinicaltrials.gov) should be consulted for a list of current trials using [18F]-FDOPA. As of May 2013, thirteen clinical trials were listed, with six trials that were accruing patients. Developed by the SNMMI PET Center of Excellence and the Center for Molecular Imaging Innovation & Translation May 2013 - 4 Fluorodopa F-18 [18F]FDOPA 18 Reference Site / Person The best reference site for F-FDOPA trials is www.clinicaltrials.gov. Imaging Protocol The imaging protocol for 18F-FDOPA can vary. Since 18F-FDOPA influx is inhibited by competition from other amino acids, patients should fast for at least 4 hours prior to tracer injection. Liberal water intake is allowed. If carbidopa is used for premedication (see above), 200 mg carbidopa is administered orally, followed by radiotracer injection at least 1 hour later. The injected activity may be in the range of 6-12 mCi (222-444 MBq). For research purpose, dynamic studies may be acquired for an extended period of time. If static imaging only is performed, data acquisition may start at ~ 10 min after 18F-FDOPA injection. Human Imaging Experience In the US 18F-FDOPA is classified as an investigational new drug (IND). An IND application is needed for clinical and research use. NDA is new drug application, aNDA is an abbreviated new drug application. Potential applications of proven clinical value include: 1. Neurology/Psychiatry: 18F-FDOPA is used for the study of presynaptic striatal dopaminergic function in neurologic disorders (DDx of Parkinson’s disease versus other neurodegenerative diseases with motor dysfunction). Decreased (initially often asymmetrical) tracer uptake in the putamen (in advanced stages also involving the caudate nucleus), in conjunction with normal 18F-FDG uptake, is a characteristic finding in patients with Parkinson’s disease. Several psychiatric syndromes have been associated with abnormalities in Dopamine synthesis, storage, dopamine receptor expression, density and activation (reviewed in Patel et al. (13)). The dopamine hypothesis continues to be investigated in schizophrenia, and studies using 18F- FDOPA have shown increased tracer uptake in the presynaptic striatum, which may then lead to enhanced dopamine release into the synaptic cleft (14). 2. Oncology a) Neuroendocrine tumors: 18F-FDOPA is an excellent tracer for imaging NET, including pheochromocytoma, extraadrenal paraganglioma (PGL), medullary thyroid carcinoma, gastro-entero-pancreatic Developed by the SNMMI PET Center of Excellence and the Center for Molecular Imaging Innovation & Translation May 2013 - 5 Fluorodopa F-18 [18F]FDOPA (GEP) NE tumors (reviewed in (15)). In NET, 18F-DOPA may be particularly useful in patients with negative 68Ga-somatostatin analogs and elevated serotonin levels (15b). 18F-FDOPA appears superior to MIBG for detecting extraadrenal and hereditary pheochromocytomas and paragangliomas (16). 18F-FDOPA may perform particularly well in patients with PGL who do not carry a SDHB mutation (17). (However, in pts with metastatic pheochromocytoma or PGL, 18F-FDG or 18F- Fluorodopamine may perform better
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